Infection & inflammation Flashcards by Amy Spicer

What is infective endocarditis?

An infection involving the endocardium including the valvular structures, the chordae tendineae, sites of septal defects, or the mural endocardium.

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How does infective endocarditis occur?

Non-bacterial thrombotic endocarditis (sterile platelet vegetation due to Venturi effect) acts as pre-requisite for adhesion and invasion → bacterial infection (usually via skin) penetrates endocardium of heart → intracardiac effects (valvular insufficiency) & systemic effects

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What are the causes of endocarditis?

Staph Aureus (IVDU)
Strep Viridans (Dental)
Staph Epidermis (Prosthesis)
Pseudomonas
HACEK organisms

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What are the risk factors for endocarditis?

Valvular disease
Rheumatic fever/valve disease
Structural congenital issues (ASD, VSD, PDA)
Hypertrophic cardiomyopathy
IVDU

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What are the Sx of acute infective endocarditis?

Fever + new murmur = ENDOCARDITIS UNTIL PROVEN OTHERWISE
Fever >38/chills/rigors
HF- dyspnoea, crackles

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How does sub-acute infective endocarditis present?

Fever >38, chills, rigors
Weight loss
Fatigue
Flu-like Sx

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What are the signs of infective endocarditis?

Osler’s nodes: Painful pulp of finger
Roth spots: Retinal haemorrhages with pale centre
Janeway lesions: Irregular, painless, erythematous macule on hypo/thenar eminence
Splinter/Subungal haemorrhages
Petechiae: Conjunctiva, hands/feet, chest/abdo, oral mucosa
Clubbing

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What murmur is heard in infective endocarditis?

AORTIC REGURG- Diastolic murmur & collapsing pulse

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What criteria is used to diagnose infective endocarditis?

Duke’s criteria:

2major
1major + 3minor
5minor

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What are the investigations for infective endocarditis?

-3 serial blood cultures in 24hours
-TTE/TOE
Bloods: FBC, Film, CRP, ESR, LFTs
Urinalysis
ECG
CXR

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How is infective endocarditis managed?

BUFALO if Septic
IV Abx: 4-6w Empirical =
NORMAL: Amox +/- Gent or Vanc + Gent
PROSTHETIC: Vans + Rifamp + Gent

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What are the antibiotics used against specific organisms causing infective endocarditis:?

Staph = Fluclox >4w
Staph (prosthesis) = Fluclox + Rifamp + Gent for 6w
Strep = BenPen 4-6w
Enterococci/HACEK = Amox + Gent

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What are the complications of infective endocarditis??

CVA: Stroke/TIA

Congestive cardiac failure

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What are the major and minor components in Duke’s criteria?

MAJOR:
- Positive blood culture in 2 separate cultures
-Evidence of IE: mass on valve, abscess, new valvular regurg
MINOR:
- Predisposing heart condition
-IVDU
-Fever >38
-Vascular phenomenon: Janeway nodes, etc
- +ve blood culture not meeting major criteria
-Immunological: Osler nodes, RF, roth spots, GN

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What is rheumatic fever?

Develops 2-6w following immunological reaction to recent Strep Pyogenes infection

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How is rheumatic fever diagnosed?

2 major criteria
1 major criteria + 2 minor
Evidence of recent strep infection

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What are the major & minor criteria for rheumatic fever?

MAJOR: Erythema marginatum, Sydenham’s chorea, Polyarthritis, Carditis (endo-, myo- or peri-), Subcut nodules
MINOR: ↑ESR/CRP, Pyrexia, Arthralgia, Prolonged PR

What is pericarditis?

Inflammation of the pericardial sac

How does pericarditis cause problems?

Volume of pericardial fluid ↑ in serous pericardium or thickens (pericardial effusion)
Pressure on heart
DIASTOLIC HF → ↓SV ↓CO

What is chronic pericarditis?

> 6m

↑fibroblasts = ↑fibrin resulting thick and stiff pericardium → pressure on heart → ↓SV → ↑HR)

What are the causes of pericarditis?

Idiopathic
Viral: Coxsackie B
Dressler Syndrome
Uraemic
Autoimmune diseases (RA, SLE)
Cancer + RT

How does pericarditis present?

Fever
Central chest pain: Pleuritic, worse when supine, relieved by leaning forwards, radiates to neck
Dyspnoea
Pericardial rub, ↓heart sounds

How is pericarditis investigated?

ECG: QRS changes
Stage1) Saddle ST elevation, PR depression
Stage2) ST normal, flattened T waves
Stage3) T waves invert
Stage4) Normal ECG
CXR: Pericardial effusion- Water bottle sign
ECHO:
Acute= heart looks like it’s ‘dancing’ in pericardial sac
Chronic = heart stiff & constricted

How is pericarditis treated?

Rest
Tx cause: Dialysis = uraemia
Analgesia: NSAIDs- Naproxen

What medication should be stopped in pericarditis?

Corticosteroids- worsen oedema/effusion | Phenytoin

What are the complications of pericarditis?

Conversion to chronic Tamponade Effusion Constrictive

What is pericardial effusion?

Increased accumulation of fluid in serous pericardium | 50ml → 2 L

What are the types of fluid in pericardial effusion?

Transudative Exudative Blood

How can pericardial effusions be grouped?

LARGE: Associated w/malignancy, TB, uraemic, myxoedema LOCULATED: Common w/scarring- post-op/trauma

What are risk factors for pericardial effusion?

``` Idiopathic Infectious: Viral, TB, HIV, Syphilis, Bacterial MI AKI/CKD: Uraemic Malignancy Hypothyroidism ```

What are the Sx of pericardial effusion?

``` Chest pain/pressure/discomfort- worse when supine, better sitting forward Cough/dyspnoea Hoarseness Dizzy & syncope Palpitations Anxiety Confusion Pericardial rub Ewart's sign: Large effusion compressing LLL causing bronchial breathing ```

How is a pericardial effusion investigated?

CXR: Water bottle sign ECG: Low voltage QRS complexes ECHO: ECHO-free zone

How is pericardial effusion managed?

Supportive Tx cause Pericardiocentesis

What are the complications of pericardial effusion?

Cardiac tamponade

What is lymphoedema?

Progressive swelling of a body part (usually limb) following disruption of the lymphatic system Results in lymph accumulating in interstitial space

What are the common causes of lymphoedema?

80% affected before lymphoedema occurs - Lymphatic hypoplasia - Obstruction - Fibrosis - Malignancy & Cancer Tx (LN dissection, RT, neoplastic infiltration) - Nematode infection - Trauma (penetrating)

How are lymphoedema causes categorised?

PRIMARY: Rare, idiopathic & usually sporadic SECONDARY: Occurs post-injury or Tx

How does lymphoedema present?

Hx of trauma/malignancy Limb heaviness/weakness Non-pitting oedema Skin changes: Hyperkeratosis, papillomatosis, induration, exudative (lymph fluid)

How is lymphoedema investigated?

Lymphoscintigram: Inject isotope into area, wait 45m-2hr then image shows areas of no uptake

How is lymphoedema managed?

``` 1) Skin care: Moisturise, bathing, protective clothing AND Compression bandaging AND Elevation AND Exercise & weight control 2) Manual drainage ```